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Frequently asked questions about concussions

The National Hockey League long has been proactive about the prevention of concussions among its players. Here's a list of frequently asked questions and answers drawn from comments by Commissioner Gary Bettman and Dr. Reuben Echemendia, head of the NHL/NHLPA Concussion Working Group:

What has the NHL done about concussions?

Bettman: "In 1997 we were the first professional sports league to start a working group for the study of concussions. It included the Players' Association, physicians, trainers. We were the first sport to mandate neuropsychological baseline testing.

"We have also mandated changes to the rules. We have mandated changes to equipment. We have mandated changes to the playing environment. All designed to increase player safety.

"We were also the first professional sports league to implement diagnosis and return-to-play protocols. For better or for worse -- and unfortunately, I suppose, because we have to deal with concussions at all, when it comes to concussion evaluation and management protocol, we have experience, and we will continue to be proactive in this area."

Echemendia: "Throughout the time since we started the program in 1997, we've been constantly reworking the program, updating the program based on the research that we have done internally in order to move ahead and improve conditions for the players as well as improve our diagnostic accuracy.

"We've done a lot of work to take a look at how our testing instruments function with our players across a number of different language groups, across a number of educational groups, and how well our tests are picking up these injuries when we examine the players post-injury. We've also begun to understand in greater detail how the concussions are being caused in the NHL and using video analyses, for example, that have led us to provide data to the League that has subsequently led to rule changes."

Has the implementation of Rule 48, the rule preventing lateral or blind-side hits where the head is the primary point of contact, made a difference?

Bettman: "Since the implementation of Rule 48 last March … we've seen a decrease in concussions and man-games lost resulting from blind-side hits to head. In addition, we have seen a decrease in concussions caused by hits involving the head that are deemed legal in our game."
What are the latest trends on player concussion for the current season?

Bettman: "What I'm about to say is based on very preliminary data so you can't hold me to it down the road with precision, because we have to make sure it bears out. But I do want to emphasize what appear to be preliminary trends. For the 2010-11 regular season, concussions are up. Again, I want to emphasize it's preliminary.

"The increase in concussions appears to be in the area of accidental or inadvertent situations as most did not involve any contact whatsoever with the victim's head by an opponent. I'm not saying no concussions came from hits to the head, but it appears the increase is coming from somewhere else.

"We've seen players concussed when they collide with teammates, and when they were hit legally and without head contact after which their heads have struck either the ice or the boards or the glass. The biggest increase in instances of concussion this season and the biggest increase in man-games lost is from these types of so-called accidental or inadvertent contact.

"With regard to fighting, the number of concussions and man-games lost due to fighting has increased. Finally, with regard to accidental or inadvertent collisions, the number of concussions caused by accidental plays on the ice and inadvertent collisions with an opponent has more than doubled year to year and has resulted in a three-fold increase in man-games lost."

Is there an explanation for the increase in accidental and inadvertent hits that have resulted in concussion?

Bettman: "Anything at this point would be speculation. We have people who are expert who review the videos. I think they've reviewed probably 85 percent of the concussions that have been taking place. Our hockey operations people do the same thing. We don't have any answers yet. It's speculation.

"It could be the speed of the game. It could be a variety of things in case of the fighting, concussions being up. It may be mismatches. These are all things we're looking at.

"The point I wanted to convey is it's easy to say the league needs to do X, Y and Z on concussions. It's not that simple. Changing a rule which doesn't address what's actually causing the concussions may not be the right thing to do. Changing equipment may not necessarily be the right thing to do.

"We spend a lot of effort on this subject. We know it's important. But we need to be very professional, smart, thorough in dealing with it."
What's the next step in the process?

Bettman: "The general managers have their meetings in March. They will obviously, as they did last year, spend time figuring out what this all means and what, if anything, needs to be done to address this issue.

"As all hockey fans, I'm unhappy about the fact that we have players who were not at the All-Star Game because of concussions. In fact, I don't like the fact that any players don't play or miss games because of concussions. But keep in mind our teams have collectively about 800 players. There are 1,230 regular-season games. We have more than 50,000 hits and about 75,000 minutes of playing time.

"Of course, the ideal number of concussions would be zero. And our objective is to come as close as possible to getting that result without changing the fundamental nature of our game. But we do want to look for ways to better protect heads and do everything possible to eliminate concussions."

Does the NHL have a protocol for what goes on in terms of a concussed player and how he can then come back onto the ice?

Echemendia: "When a player comes off the ice and is suspected of having a concussion, the team athletic trainer, typically on the bench, will do an initial evaluation. If that evaluation raises concern with respect to concussion, then that player is taken to the dressing room, where a more extensive evaluation is undertaken by the team physician and the team athletic trainer.

"If at that time the player is determined to have had a concussion, then that triggers the concussion protocol, which means the player must be kept out of play until they are symptom-free, both at rest and on exertion. They are also then tested with a neuropsychological -- fairly extensive neuropsychological test battery conducted by the conducting neuropsychologist for each team. Those test data in consultation then go to the team physician, who integrates all of the data and makes the return-to-play decision.

"Throughout that process, we put the player through a gradually increasing intensity of physical exercise to see whether the physical provocation brings about any symptoms."

Is it true there's no helmet out that can prevent a concussion?

Echemendia: "I absolutely agree with that. Given our current technology, there's nothing out there that is going to prevent a concussion, because in order to prevent a concussion, a helmet has to be able to absorb a significant amount of the blow as opposed to translating the force of that blow. The current polycarbonate shells that we have, those hard shells, they tend to just transfer the blow. They tend not to absorb the blow. And they do that for a very good reason, and that is the helmets that we have are very good at preventing what they're designed to prevent, and that is, as you say, depressed skull fractures, lacerations, significant head injuries. They were never designed to protect against concussion.

"As a matter of fact, there was some concern among the biomechanists that if we tried to make a helmet that prevents concussion; we may be going in the other direction and see an increase in skull fractures and these other types of injuries. So it's a complicated issue."

Can a mouth guard help in terms of preventing concussion?

Echemendia: "There are no clinical data to suggest that mouth guards protect against concussion. They do a very good job at protecting against dental injury, and good mouth guards should be worn for that reason. But there's no indication right now that they're effective at preventing concussion."